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Corticosteroid for Vitiligo

Corticosteroids are an important drug class used in the treatment of vitiligo early on. Although their use is being is superseded by other alternatives, they still remain a simple, easy to use vitiligo medications.
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What is a Corticosteroid?

Corticosteroid refers to a class of natural and synthetic compounds including steroid hormones and their analogs. Natural corticosteroids are produced from cholesterol in the adrenal cortex.

Corticosteroids are important to many physiological and biochemical processes in the body. They are involved in inflammation, immune response, electrolyte balance and metabolism.

Glucocorticoids are one class of corticosteroids that control the metabolism of proteins, carbohydrate fat. They also have anti-inflammatory properties. A prime example of glucocorticoids is cortisol.

Mineralocorticoids, on the other hand, are the corticosteroids that control electrolyte balance and water levels in the body. They promote the reabsorption of sodium in the kidney. Aldosterone is an example of mineralocorticoids.

There are other ways of classifying corticosteroids.

Corticosteroids By Chemical Structures
  • Group A or Cortisones – Hydrocortisone, Cortisone, Prednisolone and their salts
  • Group B or Acetonides – Triamcinolone, Budesonide, Halcinonide
  • Group C or Betamathasone-like – Bethamethasone, Dexamethasone and their salts
  • Group D or Esters – Ester salts of the above corticosteroids

Corticosteroids are formulated to be delivered by different routes of administration. The most popular dosage forms in which corticosteroids are presented are oral and topical forms. However, corticosteroids can also be formulated as inhalation, ophthalmic and injectable medications.

Synthetic corticosteroids can have one or both glucocorticoid and mineralocorticoid activities.

For example, dexamethasone is a glucocorticoid, fludrocortisone is a mineralocorticoid while prednisone has both mineralocorticoid and mineralocorticoid activities.

Glucocorticoids are more widely used than mineralocorticoids. Some of the medical conditions treated with glucocorticoids are arthritis, dermatitis, hepatitis, sarcoidosis, inflammatory bowel syndrome and lupus.

Corticosteroids can have very serious side effects and they are rarely recommended for long-term use.

Mineralocorticoids, for example, can cause hypertension, elevated sodium levels and low potassium levels. These side effects are due to the retention of sodium in the kidneys.

Long-term side effects of corticosteroids include insulin resistance, diabetes mellitus, osteoporosis, depression, erectile dysfunction and hypothyroidism.

Topical corticosteroids can cause stretch marks and unsightly lesions as well as shrink and thin the skin.

Corticosteroids can also suppress the immune system and inhibit the process of wound healing. It is also not recommended for pregnant women because of teratogenic side effects.

Why Corticosteroids Work for Vitiligo

The desirable property of corticosteroids in vitiligo therapy is its immunosuppressive effect.

Vitiligo is caused by the progressive destruction of melanocytes. Melanocytes are the specialized skin cells responsible for producing melanin, the pigment that gives the skin its color. It is when these cells are lost that the skin loses its color and white patches appear.

Different causes have been proposed for vitiligo. These include autoimmune attack on melanocytes, intrinsic defects in melanocytes, nerve damage, oxidative stress and genetic factors. However, the most popular of these proposed theories is autoimmune attack on melanocytes.

In a way, vitiligo can be described as an autoimmune disorder. It has been reported to present along with other autoimmune disorders such as thyroid dysfunction, diabetes mellitus and alopecia areata.

When the cells of the immune system see melanocytes as foreign bodies, they attack them.

There are clear evidences that both cellular and humoral immunity are involved in the destruction of melanocytes. For example, specific antibodies and CD8+ T cells are found in high levels in vitiligo patients.

Corticosteroids can prevent this autoimmune attack on the melanocyte by suppressing the immune system. By blocking the cells of the immune system, corticosteroids spare melanocytes and allow the production of melanin to proceed.

Therefore, the immunosuppressive property of corticosteroids can help stop the depigmentation of the skin and even repigment vitiligo patches.

Studies on the Use of Corticosteroid in Vitiligo Treatment

Oral Corticosteroid

In a 2003 study published in the Indian Journal of Dermatology, Venereology and Leprology, the efficacy of low dose oral corticosteroid was tested in 100 vitiligo patients.

Each of the patients were given 0.3 mg/kg of body weight of prednisolone for 2 months. This dose was then halved in the third month and further halved in the fourth month. After 4 months, the patients were then evaluated.

The results showed that depigmentation stopped in 90% of the patients and 76% of the patients experienced repigmentation.

The low dose of oral corticosteroid was used to minimize side effects.

This study showed that low dose, oral corticosteroids can be effective in the treatment of rapidly spreading vitiligo while producing no serious side effects.

Topical Corticosteroids

A 1976 study published in the British Journal of Dermatology recruited 20 vitiligo patients for a trial of 2 topical corticosteroids.

The patients were divided into 2 groups. One group received 0.05% clobetasol propionate and the other group were given 0.1% betamethasone valerate. After 3 months of treatment, the patients were examined.

The results showed that both topical steroids were effective in the treatment of vitiligo in some (and not all) patients. Also, more patients experienced repigmentation with betamethasone valerate than clobetasol propionate.

Combination Corticosteroid Therapy

A 2004 study published in the journal, Pediatric Dermatology, accessed the benefits of combining topical corticosteroid with another vitiligo medication. The result was then compared with treating with only corticosteroids.

In this study, 12 vitiligo patients were advised to use topical corticosteroids in the morning and calcipotriene in the evening.

Calcipotriene is a vitamin D analog that has been proven to improve vitiligo spots especially when combined with ultraviolet irradiation (UVA and UVB).

The results of this study showed that 83% of the patients responded to treatment with the combination of calcipotriene and corticosteroids. In this group are 4 patients who had been unsuccessfully treated with corticosteroids. Of the successful cases, 95% of the patients experienced full body repigmentation.

This study showed that vitiligo cases that did not respond to corticosteroid may be successful treated by combining corticosteroids with other vitiligo treatments.

How to Use Corticosteroid for Vitiligo

While many report that oral corticosteroids produce better results than topical corticosteroids, many prescribers advise against treating vitiligo with oral corticosteroids because of their serious side effects.

Furthermore, it is easier for prescribers and patients to monitor topical corticosteroids and withdraw them at the first signs of side effects.

Generally, oral corticosteroids are reserved for severe vitiligo cases but even those cases can be treated with other safer, topical vitiligo drugs such as tacrolimus and vitamin D analogs like calcipotriene.

Corticosteroids are not recommended for treating vitiligo patches that occupy large areas of the skin. They work best for localized vitiligo. They should also be avoided when vitiligo spots affect highly visible parts of the body such as the face.

Besides topical vitiligo drugs such as calcipotriene, topical corticosteroids can also be combined with ultraviolet light therapy. Different studies have shown that this combination produces better results than each treatment used alone.

Only low strength topical corticosteroids should be used for children.

When some researchers analyzed the body of studies done on the use of corticosteroids in the treatment of vitiligo, it was concluded that class 3 and class 4 topical corticosteroids were the most effective.

Corticosteroids in these classes include betamethasone valerate, hydrocortisone butyrate, methylprednisone, clobetasol propionate and betamethasone dipropionate.

Clinicians recommend that topical corticosteroid therapy should be stopped if no significant improvements are seen after 2 months of treatment.

Where low dose oral corticosteroid therapy is not possible, high dose pulse therapy may be advised. This form of treatment involves short treatment with intravenous corticosteroids.

Sources


http://www.skintherapyletter.com/2008/13.2/1.html

http://www.ijdvl.com/article.asp?issn=0378-6323;year=2003;volume=69;issue=2;spage=135;epage=137;aulast=Banerjee

http://www.nvfi.org/pages/vitiligo_treatment.php

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